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Application For Electronic Access Of Records - Nebraska

Application For Electronic Access Of Records Form. This is a Nebraska form and can be used in Limited Liability Company Secretary Of State .
 Fillable pdf Last Modified 10/16/2007
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APPLICATION FOR ELECTRONIC ACCESS OF RECORDS TO BE USED ONLY BY LIMITED LIABILITY COMPANIES PROVIDING HEALTH RELATED PROFESSIONAL SERVICES John A. Gale, Secretary of State Room 1301 State Capitol, P.O. Box 94608 Lincoln, NE 68509 http://www.sos.state.ne.us Name of Limited Liability Company_________________________________________ Principal Place of Business________________________________________________ Street Address City State Zip Practice of_____________________________________________________________ Please name profession company is engaged in Telephone Number ( ) _______________________ MEMBERS OF THE LIMITED LIABILITY COMPANY This Section Must be Completed. List all members of the limited liability company who are required by Nebraska law to be licensed or certified to perform the professional services for which the limited liability company was organized. (use additional sheets if needed) _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip FILING FEE: $50.00 Revised 12/04/06 Neb. Rev. Stat. 21-2631.01 (Please Complete Reverse Side) MANAGERS OF THE LIMITED LIABILITY COMPANY American LegalNet, Inc. www.FormsWorkflow.com This Section Must be Completed. List all managers of the limited liability company who are required by Nebraska law to be licensed or certified to perform the professional services for which the limited liability company was organized. (use additional sheets if needed) _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip PROFESSIONAL EMPLOYEES OF THE LIMITED LIABILITY COMPANY This Section Must be Completed. List all professional employees of the limited liability company who are required by Nebraska law to be licensed or certified to perform the professional services for which the limited liability company was organized. (use additional sheets if needed) _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # _____________________________________ Full Name & License # Signature of Member ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip ____________________________________ Residence Street Address, City, State, Zip Signature of Manager _____________________________________ or ____________________________________ ________________________Date Printed Name of Member Revised 12/04/06 / / or ______________________Date Printed Name of Manager / / American LegalNet, Inc. www.FormsWorkflow.com
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